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Michael Fox, PCC, LCDC III
OACCA Spring
Conference 2014
98 Years of Leadership in Social Justice

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1.
Participants will understand the unique aspects of youth with cooccurring disorders, including: developmental influences; differential diagnostic challenges; and family, peer and community considerations.
2.
Participants will understand the basic clinical concepts related to implementation of ICT, including; home-based and system of care frameworks, integrated case conceptualization and utilizing an integrated framework for screening, assessing and treating youth with co-occurring disorders.
3.
Participants will identify collaborative considerations related to the implementation of a co-occurring, home/community based program.
Center for Innovative Practices

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Service to Science Development
Initial Model Development:
U. of Akron, 1999
Phase One
Naturalistic progression based on community need. Expert panel; focus groups; youth and family
Phase Two
Pilot Implementation: 2001-2005
Model refinement; small comparison study. High family and community saliency.
Phase Three
Multiple Site Implementation: 2005-
Present
Initial research study: 2005-2008
Model refinement
Phase Four: Develop Increasing Research Support
Center for Innovative Practices

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ICT utilizes an integrated treatment approach, embedded in an intensive home-based method of service delivery, to provide a set of core services to youth with co-occurring disorders of substance use and serious emotional disability and their families.
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Addresses the reciprocal interaction of how each disorder affects the other, in context of the youth’s family, culture, peers, school, and greater community
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Prioritizes saliency and immediacy of need which may fluctuate from session to session
Center for Innovative Practices

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Simply and globally: when a mental health disorder and a substance use disorder occur at the same time
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More individually and specifically: “when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from [a single] disorder”.
(CSAT, 2005)
Center for Innovative Practices

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1.
2.
3.
4.
5.
Youth with COD present with multiple and complex symptom patterns and behaviors, which adversely affects their functioning in developmentally important life domains.
Sustained recovery often takes multiple treatment attempts over time.
COD presentation in youth is affected by brain development; and conversely, brain development is impacted by substance use.
Contextual factors (peers, family, school, neighborhood, and the risk and protective factors associated with them) play a mediating role in youth behaviors, use patterns, and recovery trajectory.
The stressors associated with co-occurring disorders negatively strain family emotional, interpersonal, and material resources.
Center for Innovative Practices

Family and
Genetics
Erikson
Identity v. Role
Confusion
Teenager
Prefrontal
Cortex
Development
Sexual
Maturation and
Pressures
Kohlberg:
Postconventional explorations
Center for Innovative Practices

Triadic Model
Ersnt, Romeo and Andersen (2009)
Striatum
(Approach)
Prefrontal
Cortex
(Modulation) interaction
Amygdala
(Avoidance)
Implications for risk-taking
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Prefrontal Cortex: selfmonitoring and inhibitory
Amygdala: conditioned fear and avoidance
Striatum (includes nucleus accumbens): motivation and incentive
Adolescents appear to weigh risk more heavily toward reward and discount loss – riskier choices
Center for Innovative Practices

Developmental Differences Between Adolescents and Adults
Youth Adults
Multiple system mandates; including parents
Fewer mandates; increased life responsibilities
Less developed executive functioning: Poor self regulation; planning; judgment; weighing consequences; and impulse control
Executive functioning more fully developed
Vulnerable & Abstract; Independent Invincible & Concrete; Situational
Independence
Earlier stage of disorders Fully developed disorders
Pattern of use; drug of choice Pattern of substance use-opportunistic; discontinuous; intensive
Increased impact of peer influence on use and relapse
Consequences have less impact
Dependency guides use more than peers
Additive effect of consequences over time
Life perspective: lack of past knowledge & future orientation
Life perspective-experiences inform choice
Gathering experiences (Increased thrill Preserving life seeking behaviors; interest in novel stimuli)
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Multiple problems (5+) are the norm (Dennis, 2005)
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Trauma and victimization in 62 to 80% of youth (Dennis; Hussey)
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Most youth have multiple system involvement and problems (juvenile justice (81%); schools; family; peers)
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Treatment engagement and retention are difficult, and intervention outcomes tend to be poor, (Hawkins, 2009)
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Chronic relapsing disorder, requiring multiple treatment attempts over time (White and Dennis)
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Is Multiple-Occurring Condition a better frame?
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Exposure to multiple traumatic events: can be quite pervasive and more difficult to identify (when compared to PTSD, which is in response to a single event)
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Can develop with repeated abuse, neglect, exposure to violence/DV – high stress neighborhoods or families.
National Child Trauma Stress Network
Center for Innovative Practices

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Hendrickson, 2009
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Chronic or complex trauma has been associated with adolescents reacting to stressful situations with uncontrolled hopelessness and rage
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Affect regulation is also impacted: youth may have difficulty identifying feelings and struggle to understand how to safely express emotions
Center for Innovative Practices

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ACE
Abuse
 physical
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 emotional sexual
Neglect
 emotional
 physical
Household Dysfunction
 mother treated violently
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 household substance use household mental illness
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 parental separation/divorce incarcerated household member
Increased Risk Areas:
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 alcohol drug use
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COPD depression fetal death heart disease liver disease intimate partner violence smoking adolescent pregnancies early sex; multiple partners suicide attempts
 more…
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Substance abuse is common in JJ involved youth, has a strong influence on delinquent behavior and delinquency recidivism
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Substance abuse problems influence the likelihood that youth will associate with other delinquent youth in high risk situations
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Substance use impairs a youth’s impulse control and judgment, which further increases the likelihood of behaving in a risky or harmful manner
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Mental health symptoms or psychosocial stresses can be numbed, or exacerbated by the use of substances.
Center for Innovative Practices

Contextual
Factors
Substance Use
Disorder
Trauma and
Safety
Family
History
Development
Mental Health
Disorder
Center for Innovative Practices
Behaviors
Symptoms
Adapted from Shepler

Contexts (Home,
School, Peers,
Community, etc.)
Substance Use
Disorder
Mental Health
Disorder
Family
Trauma Factors
Youth
Salient
Behavior/
Symptom
Risk & Resiliency
Factors
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Developmental
Factors Safety Concerns Center for Innovative
Practices

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Home-Based Service Delivery
Modality
Systemic Engagement and Change
Multidimensional and Integrated
Assessment and Conceptualization
Comprehensive and Integrated
Treatment Array Matched to
Needs and Strengths
Center for Innovative Practices

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Location of Service
Home-Based Service Delivery Model
Home and Community
Intensity Frequency: 2 to 5 sessions per week
Duration: 4 to 8 hours per week
24/7 Crisis response & availability; active safety planning and monitoring
Active safety planning & monitoring Ongoing
Small caseloads 4 to 6 families per FTE; 8 to 12 for team of two
Flexible scheduling
Treatment duration
Convenient to family
3 to 6 months
Systemic engagement and community teaming
Child and family teaming; skillful advocacy; family partnering; culturally mindful engagement
Active clinical supervision & oversight 24/7 availability; field support; individual & group
Program structure and credentials
Comprehensive service array
Licensed BSW and above; MA preferred
Program size: 4 to 8; .5 to 1 FTE IHBT Supervisor
Individual provider versus teaming approach
Crisis stabilization, safety planning, skill building, trauma-focused, family-focused; resiliency & supportbuilding interventions; cognitive interventions

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Engagement and Assessment (High Intensity)
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Engagement (youth, family, & collaborative partners)
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Crisis Stabilization and Safety Planning
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Assessment
Treatment (High to Medium Intensity)
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Evidenced-based individual and family treatments and supports
Skill Building, Skill Consolidation, and Generalization
Enhancement of Positive Support Network
Preparation of Continuing Care and Support Needs (Decreasing
Intensity)
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Solidify continuing care and support needs
Linkages, Closure, & Follow-up
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Increased reliance on informal supports
Center for Innovative Practices

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I.
Symptom Patterns and Diagnoses: youth who meet the criteria for both Mental Health and Substance Use diagnoses
II.
III.
Contextual Functioning: Degree of functional impairment per life domain
Developmental and Cognitive Functioning: (cognitive functioning, emotional, & behavioral maturity)
IV.
Risk and Recovery Environments: Environmental risk and recovery conditions (e.g. trauma, safety, negative influences, family conflict, poverty)
The youth’s functioning and COD patterns are determined by integrating these areas in context of the other and as a collective whole.
Center for Innovative Practices

School
+
-
+
Family
Youth
-
Peers
+
-
Informal Supports
+
-
Community
+
-
+ = Protective Factors
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-
= Risk Factors
+
-
Work
Center for Innovative Practices

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An increase in two or three assets for a low asset youth (10 or less) has greater influence on reducing substance use behavior than with high asset youths
(31 or more)
Adding developmental assets reduces ATOD use at all levels of developmental assets
Youth with higher amounts of assets in the external asset categories of Supports and Boundaries and
Expectations were less likely to initiate ATOD use than youth with less assets in these categories
Center for Innovative Practices

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Boundaries & Expectations
Family boundaries
Supports
Family support
School boundaries
Neighborhood boundaries
Adult role models
Positive peer influence
Positive family communication
Other adult relationships
Caring neighborhood
Caring school climate
High expectations Parent involvement in schooling
Center for Innovative Practices

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(Externalizing Behaviors: Hawkins and Catalano)
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Community: availability of drugs; economic deprivation
Family: family conflict; family management problems; low warmth
School: academic failure; lack of commitment
Individual and Peer: early and persistent anti-social behavior; rebelliousness; negative peers; favorable attitudes toward drugs, impulsivity;
Trauma: History of physical, sexual, and emotional abuse
(Dennis, 2004)
Center for Innovative Practices

Contextual & Relational Dynamics:
Family, Peers,
School, Community
Dispositional
Factors
Youth
SU Disorder
De-stabilizing
Event or Trigger
Salient
Behavior/
Symptom
Exacerbating
Response
MH Disorder
Trauma Filter
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© 2011, R. Shepler,
Center for Innovative Practices
Risks Factors, Skills,
Resources, and Supports
Escalation Cycle
Safety
Issue

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Crisis Intervention and Stabilization
Case management-oriented activities to meet basic needs
Individually-Focused Interventions
Family-Focused Interventions
Cross-System Interventions
Resource and support building activities
Center for Innovative Practices

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Recovery &
Resiliency
FUNCTIONING &
SUPPORTIVE
ENVIRONMENTS
DEVELOPMENTAL SKILL
SETS
BASIC NEEDS & SAFETY
Youth and Family Need Hierarchy (Shepler, 1991, 1999)
Center for Innovative Practices

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Formulate integrated conceptualization of the interaction between SU and MH behaviors in context
Utilize Principle of Saliency
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Which mental health and/or substance use behaviors are most urgent and/or problematic?
In what contexts are these behaviors of most concern?
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Which concerns if not addressed could spiral into bigger problems?
What poses the greatest risk or stressor to the youth and family?
Which assets, skills, supports or resources best promote resiliency and recovery for this youth?
Center for Innovative Practices

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Structure
LOS: 6 months
Caseload: 4 to 6 youth/families
On-call 24/7 as a team
24 hour availability of supervisors for each therapist
Field supervision as needed
Dually certified agency; dually licensed supervisor
2 to 4 FTE clinical staff either dually licensed or dually trained, with mix of SU and MH expertise on the team
Weekly consultation, training, and technical support
Center for Innovative Practices
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Dually certified agency; dually licensed supervisor
2 to 4 FTE clinical staff either dually licensed or dually trained, with mix of SU and MH expertise on the team
Consultation, training, and technical support:
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Provide initial and booster trainings
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Provide regular consultation and coaching of ICT Team
Years 3+:
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ICT Supervisor Monitors Fidelity
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Consultation negotiated based on need
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Yearly fidelity review
Center for Innovative Practices
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ICT is typically funded through a combination of
Medicaid, insurance, and cross-system funding.
Unique aspects of intensive home-based service delivery models that are more costly
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Extensive supervision and consultation time involved;
Small caseloads;
Travel time required to deliver the service in the natural environment; and
On-call coverage;
All of which decrease the amount of time in a week for billable services.
Center for Innovative Practices

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Center for Innovative Practices

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SAMHSA’s 2010 Science and Service Award : a national program that recognizes community-based organizations and coalitions that have shown exemplary implementation of evidence-based mental health and substance abuse interventions. Given to McHenry County for its implementation of ICT for their SAMHSA SOC grant.
NIATx iAward (2010) given by the State Association of Addiction
Services and NIATx : Family Service and Community Mental Health
Center located in McHenry County, Illinois received a 2010 iAward for Innovation in Behavioral Healthcare Services for its successful implementation of Integrated Co-Occurring Treatment (ICT).
Blueprint for Change: A Comprehensive Model for the Identification and
Treatment of Youth with Mental Health Needs in Contact with the
Juvenile: One of the programs chosen by the National Center for
Mental Health and Juvenile Justice to be highlighted as a promising practice in this OJJDP supported monograph
Center for Innovative Practices

Current ICT Sites
Summit County, Ohio
Cuyahoga County, Ohio
Franklin County, Ohio
State/Federal Funding
Byrne; JAIBG 2001-2004; Currently BHJJ
SAMHSA System of Care (2006-2008) & SCY: 2006-
2007; Currently BHJJ
Re-Entry: 2011-2012; BHJJ 2012- 2014
Lorain County, Ohio
McHenry County, Illinois
BHJJ (2014)
SAMHSA System of Care: 2008-2012
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Kalamazoo County, Michigan SAMHSA System of Care: 2006- 2009
Montana (Helena and Missoula) SAT-ED 2013- current
Center for Innovative Practices

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Increase functioning in major life contexts so that the youth is:
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Living at home or in a permanent home setting
Attending and achieving at school/work
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Reduced involvement in the JJ system
Reduced use/no use of substances
Participating in positive family, peer, and community life
Improved family recovery environment
Accessing resources and natural supports as needed to maintain gains and prevent recidivism
Center for Innovative Practices

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Results of ICT Study (2001-2002)
ICT Youth
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56 youth
25% recidivism rate
Usual Services
Comparison
Group
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19 Youth
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47% commitment rate
Size of
Difference in commitment and/or recidivism rates
Chi Square (1, 19):
3.338
Level of significance:
(p one-tailed = .034)
Center for Innovative Practices

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Real world study: Utilized naturally occurring comparison groups from a specialized co-occurring court
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Due to ethical concerns, randomization into groups was not allowed
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All youth received the co-occurring court’s intensive probation program
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Compared ICT to traditional non-integrated services (TAU)
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ICT group had significantly more problems at admission than TAU group
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Randomized controlled study with follow-up needed to confirm results
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All Youth Considered Together ICT Did Better than TSS
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Substance use variables
(GRAD; Drug Screens)
Mental health variables:
(Ohio Scales; GRAD)
Family/Parenting (GRAD)
Pro-Social Activities
(GRAD)
Educational Functioning
(GRAD)
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Substance Use Variables
(GRAD; Drug Screens)
Mental Health Problem
Severity: (GRAD only)
Pro-Social Activities
(GRAD)
Pro-Social Peers (GRAD-
Parent Rating)
Family/Parenting (GRAD-
Youth Rating)
Center for Innovative Practices

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14
12
10
8
6
4
2
0
ICT showed a significant decrease in substance use, as measured by the GRAD Substance Use/Abuse Scale, as compared to TSS
(p < 0.001)
Substance Use as Measured by GRAD Substance Use/Abuse Scale Across
Treatment and Time
Time 1 Time 2
TSS
Time 3
ICT
Time 4
Center for Innovative Practices

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ICT showed a significant decrease in mental health problem severity, as measured by the GRAD Personality/Behavior Scale, compared to TSS (p < 0.014)
GRAD 7 Across Treatment and Time
25
20
15
10
5
0
Time 1 Time 2
TSS
Time 3
ICT
Center for Innovative Practices
Time 4

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Randomized controlled study
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Sustainability and durability of results
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Think trajectory of wellness not cure
Youth living with mental health and substance use disorders often have ongoing treatment and/or support needs
Substance use is a chronic relapsing disorder (Dennis)
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Completion rates low/High rate of treatment drop-out.
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About half of adolescents treated report no use after treatment
Measure what you do: risk reduction across life domains
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Track multiple outcomes
Conversation with key stakeholders about realistic outcome expectations (increased functioning; decreased level of care needs; etc.)
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Engagement and motivation to change is slower
Optimal effects are more likely to be achieved using interventions that impact youth behaviors, family systems, peer relationships, and school functioning.
Focus on risk reduction and symptom stabilization across life domains
Intensive clinical supports are needed to help manage risk and safety
(active safety planning and monitoring, and have 24-hour on-call availability to the youth and family)
Look for treatment programs that offer both substance use and mental health approaches delivered in home and community environments such as ICT, Multisystemic Therapy (MST), Functional Family Therapy-CMT
(FFT-CMT), Multidimensional Family Therapy (MDFT).
Traditional adult-oriented programs, such as twelve step programs, may not be developmentally appropriate for youth with co-occurring disorders. Try recovery mentors.
Center for Innovative Practices

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Leveraging the influence of the court in combination with effective treatments leads to better outcomes
Managing risk and safety issues of high-risk youth in the community requires active collaboration and coordination between service providers, the family, and the court (consider utilizing Wraparound process format)
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Community service coordination planning can be incorporated into court orders.
Coordinated teaming efforts increases community accountability to a unified plan for the youth.
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Clinically-informed judicial decision making: Can utilize the clinical information provided to make informed decisions about youth
Utilize regularly scheduled staffing/teaming between service providers and juvenile justice team for purpose of problem-solving and developing creative solutions
Resolve infrastructure issues prior to implementing new programs
(integrated funding and paperwork requirements)
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Be cognizant that federal law 42CFR Part 2 is the most restrictive confidentiality law for treatment professionals and limits what treatment professionals can say about a client’s substance use without appropriate releases or unless court ordered.
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Effective intervention practices and programs
+
Effective implementation practices
= Good outcomes for children and their families
No other combination of factors reliably produces desired outcomes for children, families, and caregivers
NIRN
Center for Innovative Practices

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Rick Shepler, Ph.D., PCC-S
Center for Innovative Practices
Case Western Reserve University richard.shepler@case.edu
Patrick Kanary, Director
Center for Innovative Practices
Case Western Reserve University
Patrick.kanary@case.edu

Michael Fox M.A., PCC, LCDC III michael.fox2@case.edu
Center for Innovative Practices